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Journal of Perinatology (2023 )Cite this article Retroreflection Tester
There is no validated tool to assess iatrogenic opioid withdrawal in preterm infants in the newborn intensive care unit (NICU).
The Neonatal Withdrawal Assessment Tool (NWAT) was developed to address this gap in clinical practice. In this pilot study, the NWAT was assessed for inter-rater reliability (IRR) and content validity.
Fifty-one NICU providers scored two standardized simulated cases, then 20 paired provider assessments were completed on 5 preterm infants. The overall IRR was 95.6% on the simulated cases, and 98.8% on the 5 pilot infants. A provider survey assessed for content validity; all of the provider participants strongly agreed/agreed that the NWAT adequately measures withdrawal in critically ill infants.
The NWAT demonstrated high IRR and content validity for assessment of iatrogenic opioid withdrawal in preterm infants in this pilot study. Further studies in a larger more diverse patient population are needed before wider adoption into clinical practice.
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Given the data collected as part of this study were collected as part of an exempt quality improvement protocol, data is not available for sharing in a public repository. All relevant results from this study have been summarized in the study tables.
McPherson C, Inder T. Perinatal and neonatal use of sedation and analgesia. Semin Fetal Neonatal Med. 2017;22:314–20.
Zwicker JG, Miller SP, Grunau RE, Chau V, Brant R, Studholme C, et al. Smaller cerebellar growth and poorer neurodevelopmental outcomes in very preterm infants exposed to neonatal morphine. J Pediatr. 2016;172:81–7.e2.
Article CAS PubMed PubMed Central Google Scholar
Duerden EG, Guo T, Dodbiba L, Chakravarty MM, Chau V, Poskitt KJ, et al. Midazolam dose correlates with abnormal hippocampal growth and neurodevelopmental outcome in preterm infants. Ann Neurol. 2016;79:548–59.
Article CAS PubMed Google Scholar
Giordano V, Edobor J, Deindl P, Wildner B, Goeral K, Steinbauer P, et al. Pain and sedation scales for neonatal and pediatric patients in a preverbal stage of development: a systematic review. JAMA Pediatr. 2019;173:1186–97.
Steinbauer P, Deindl P, Fuiko R, Unterasinger L, Cardona F, Wagner M, et al. Long-term impact of systematic pain and sedation management on cognitive, motor, and behavioral outcomes of extremely preterm infants at preschool age. Pediatr Res. 2021;89:540–8.
Armbruster D, Schwirian C, Mosier A, Tam W-YM, Prusakov P. Neonatal abstinence syndrome and preterm infants: a look at current practice. Adv Neonatal Care. 2021;21:107–14.
Desai A, Aucott S, Frank K, Silbert-Flagg J. Comparing N-PASS and NIPS: improving pain measurement in the neonate. Adv Neonatal Care. 2018;18:260–6.
Benbrook K, Manworren RCB, Zuravel R, Entler A, Riendeau K, Myler C, et al. Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) with NICU nurses’ assessments. Adv Neonatal Care. 2022; https://doi.org/10.1097/ANC.0000000000000968.
Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol. 2008;28:55–60.
Article CAS PubMed Google Scholar
Morgan ME, Kukora S, Nemshak M, Shuman CJ. Neonatal Pain, Agitation, and Sedation Scale’s use, reliability, and validity: a systematic review. J Perinatol. 2020;40:1753–63.
Ruwanpathirana R, Abdel-Latif ME, Burns L, Chen J, Craig F, Lui K, et al. Prematurity reduces the severity and need for treatment of neonatal abstinence syndrome. Acta Paediatr. 2015;104:e188–94.
Article CAS PubMed Google Scholar
Allocco E, Melker M, Rojas-Miguez F, Bradley C, Hahn KA, Wachman EM. Comparison of neonatal abstinence syndrome manifestations in preterm versus term opioid-exposed infants. Adv Neonatal Care. 2016;16:329–36.
Article PubMed PubMed Central Google Scholar
Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MAQ. The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med. 2008;9:573–80.
Article PubMed PubMed Central Google Scholar
Franck LS, Scoppettuolo LA, Wypij D, Curley MAQ. Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain. 2012;153:142–8.
Zaccagnini M, Ataman R, Nonoyama ML. The Withdrawal Assessment Tool to identify iatrogenic withdrawal symptoms in critically ill paediatric patients: a COSMIN systematic review of measurement properties. J Eval Clin Pract. 2021;27:976–88.
Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2:141–58.
Jones HE, Seashore C, Johnson E, Horton E, O’Grady KE, Andringa K, et al. Psychometric assessment of the Neonatal Abstinence Scoring System and the MOTHER NAS Scale. Am J Addict. 2016;25:370–3.
Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8:1–6.
Wachman EM, Grossman M, Schiff DM, Philipp BL, Minear S, Hutton E, et al. Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol. 2018;38:1114–22.
Vyas D, Cardona VQ, Carroll A, Markel C, Young M, Fleishman R. Standardized scoring tool and weaning guideline to reduce opioids in critically Ill neonates. Pediatr Qual Saf. 2022;7:e562.
Article PubMed PubMed Central Google Scholar
Sneyers B, Duceppe M, Frenette AJ, Burry LD, Rico P, Lavoie A, et al. Strategies for the prevention and treatment of iatrogenic withdrawal from opioids and benzodiazepines in critically Ill neonates, children and adults: a systematic review of clinical studies. Drugs. 2020;80:1211–33.
Article CAS PubMed PubMed Central Google Scholar
Stokowski LA.Validation of the N-PASS.Adv Neonatal Care.2008;8:75.
Baloch RQ, Pinto JM, Greenberg P, Kuo Y-H, Siu A. Evaluation and analysis of the Modified Finnegan Scoring System for assessment of neonatal abstinence syndrome. J Opioid Manag. 2020;16:189–96.
Hambleton MT, Reynolds EW, Sithisarn T, Traxel SJ, Patwardhan AR, Crawford TN, et al. Autonomic nervous system function following prenatal opiate exposure. Front Pediatr. 2013;1:27.
Article PubMed PubMed Central Google Scholar
Jebb AT, Ng V, Tay L. A review of key likert scale development advances: 1995–2019. Front Psychol. 2021;12:637547.
Article PubMed PubMed Central Google Scholar
Zapf A, Castell S, Morawietz L, Karch A. Measuring inter-rater reliability for nominal data—which coefficients and confidence intervals are appropriate? BMC Med Res Methodol. 2016;16:93.
Article PubMed PubMed Central Google Scholar
Grunau RE, Holsti L, Whitfield MF, Ling E. Are twitches, startles, and body movements pain indicators in extremely low birth weight infants? Clin J Pain. 2000;16:37–45.
Article CAS PubMed Google Scholar
Holsti L, Grunau RE, Oberlander TF, Whitfield MF, Weinberg J. Body movements: an important additional factor in discriminating pain from stress in preterm infants. Clin J Pain. 2005;21:491–8.
Article PubMed PubMed Central Google Scholar
Sohn M, Ahn Y, Lee S. Assessment of primitive reflexes in high-risk newborns. J Clin Med Res. 2011;3:285–90.
PubMed PubMed Central Google Scholar
Allen MC, Capute AJ. The evolution of primitive reflexes in extremely premature infants. Pediatr Res. 1986;20:1284–9.
Article CAS PubMed Google Scholar
Payne V, Hall M, Prieto J, Johnson M. Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2018;103:F422–9.
Ojha S, Abramson J, Dorling J. Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice? BMJ Paediatr Open. 2022;6:e001460.
Article PubMed PubMed Central Google Scholar
McPherson C, Grunau RE. Neonatal pain control and neurologic effects of anesthetics and sedatives in preterm infants. Clin Perinatol. 2014;41:209–27.
Flannery T, Davis JM, Czynski AJ, Dansereau LM, Oliveira EL, Camardo SA, et al. Neonatal abstinence syndrome severity index predicts 18-month neurodevelopmental outcome in neonates randomized to morphine or methadone. J Pediatr. 2020;227:101–7.e1.
Article CAS PubMed PubMed Central Google Scholar
McPherson C, Miller SP, El-Dib M, Massaro AN, Inder TE. The influence of pain, agitation, and their management on the immature brain. Pediatr Res. 2020;88:168–75.
Article PubMed PubMed Central Google Scholar
We would like to thank the nursing and physician staff of the Boston Medical Center NICU for their assistance with the NWAT tool development and roll-out, particularly nurse manager Donna Stickney. No funding was provided for the conduct of this study.
Boston Combined Residency Program in Pediatrics, Boston Medical Center and Boston Children’s Hospital, Boston, MA, USA
Gonca Bektas & Taylor Soderborg
Department of Pediatrics, Boston Medical Center, Boston, MA, USA
Cheryl Slater, Michelle Racioppi, Trystan Hogan & Elisha M. Wachman
Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
Joel Agarwal & Martha M. Werler
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GB, TS, and EW created the first draft of the manuscript; EW and CS created the NWAT tool and led the roll-outs and survey; TH and MR contributed to NWAT tool development; JA and MW conducted the analysis; GB, TS, CS, and EW collected data; all authors critically reviewed and approved the final version of the manuscript.
Correspondence to Elisha M. Wachman.
The authors declare no competing interests.
This study was approved by the Institutional Review Board of the Boston University Medical Campus as an exempt protocol with waived informed consent.
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Bektas, G., Soderborg, T., Slater, C. et al. The Neonatal Withdrawal Assessment Tool (NWAT): pilot inter-rater reliability and content validity. J Perinatol (2023). https://doi.org/10.1038/s41372-023-01641-4
DOI: https://doi.org/10.1038/s41372-023-01641-4
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